Chapter 01: Critical Thinking in Health Assessment
Text Bank
MULTIPLE CHOICE
1. After completing an initial assessment on a patient, the nurse has
... [Show More] charted that his respirations are
eupneic and his pulse is 58. This type of data would be:
1. objective.
2. reflective.
3. subjective.
4. introspective.
ANS: 1
Objective data are what the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical exam.
DIF: Comprehension REF: Page: 2
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. A patient tells the nurse that he is very nervous, that he is nauseated, and that he “feels hot.” This
type of data would be:
1. objective.
2. reflective.
3. subjective.
4. introspective.
ANS: 3
Subjective data are what the person says about himself or herself during history taking.
DIF: Comprehension REF: Page: 2
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
3. The patient’s record, laboratory studies, objective data, and subjective data combine to form the:
1. database.
2. admitting data.
3. financial statement.
4. discharge summary.
ANS: 1
Together with the patient’s record and laboratory studies, the objective and subjective data
form the database.
DIF: Knowledge REF: Page: 2 MSC: NCLEX: General
4. When listening to a patient’s breath sounds, the nurse is unsure about a sound that is heard. The
nurse should:
1. notify the patient’s physician immediately.
2. document the sound exactly as it was heard.
3. validate the data by asking a coworker to listen to the breath sounds.
4. assess again in 20 minutes to note whether the sound is still present.
ANS: 3
Validate any data that you need to make sure are accurate. If you have less experience in
an area, ask an expert to listen.
DIF: Analysis REF: Page: 2
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
5. Novice nurses, without a background of skills and experience to draw from, are more likely to
make their decisions using:
1. intuition.
2. a set of rules.
3. articles in journals.
4. advice from supervisors.
ANS: 2
Novice nurses operate from a set of rules (such as the nursing process).
DIF: Comprehension REF: Pages: 2-3 MSC: NCLEX: General
6. Expert nurses learn to attend to a pattern of assessment data and to act without consciously
labeling it. This is referred to as:
1. intuition.
2. the nursing process.
3. clinical knowledge.
4. diagnostic reasoning.
ANS: 1
Intuition is characterized by pattern recognition—expert nurses learn to attend to a pattern of
assessment data and act without consciously labeling it.
DIF: Comprehension REF: Page: 3 MSC: NCLEX: General
7. Critical thinking in the expert nurse is greatly enhanced by opportunities to:
1. apply theory in real situations.
2. work with physicians to provide patient care.
3. follow physician orders in providing patient care.
4. develop nursing diagnoses for commonly occurring illnesses.
ANS: 1
The depth and breadth of expert knowledge, largely gained from opportunities to apply
theory in real situations, greatly enhances a nurse’s critical thinking ability.
DIF: Comprehension REF: Pages: 3-4 MSC: NCLEX: General
8. Which of the following is an example of a first-level priority problem?
1. A patient with postoperative pain
2. A newly diagnosed diabetic who needs diabetic teaching
3. An individual with a small laceration on the sole of the foot
4. An individual with shortness of breath and respiratory distress
ANS: 4
First-level priority problems are those that are emergent, life-threatening, and immediate
(e.g., establishing an airway, supporting breathing, maintaining circulation, and
monitoring abnormal vital signs). [Show Less]